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Internal Medicine (Nutrition_3) Dr Ammar Waham Ashor
Medical Nutrition Therapy for Gastrointestinal Tract
Disorders
Dietary habits and specific food types can play an important role in the onset, treatment, and
prevention of many GI disorders. Nutrition therapy is integral in the prevention and treatment
of malnutrition and deficiencies that can develop from a GI tract disorder.
Gastroesophageal Reflux Disease
Gastroesophageal reflux disease (GERD) is a very common disease characterised by backflow
or regurgitation of gastric contents from the stomach into the oesophagus. During reflux, many
patients feel a burning sensation behind the sternum that radiates toward the mouth, producing
the most common symptom of GERD: heartburn, which is unrelated to disease of the heart.
Other less common symptoms include iron deficiency anaemia with chronic bleeding and
aspiration, which may cause cough, dyspnoea, or pneumonitis.
MNT of Gastroesophageal Reflux Disease
• It is important for patients with GERD to avoid high-fat meals. Slow emptying of the
stomach from eating high-fat food increases sphincter relaxation, leading to potential
reflux.
• Patients should also avoid overeating, which slows emptying. Eat small frequent meals.
Reduce weight for obese patients.
• Foods such as chocolate, alcohol, peppermint, spearmint, caffeine, and high-acid foods
(tomatoes, vinegar-based foods, citrus fruits, and juices) may irritate the oesophagus and
cause heartburn.
• Avoidance of recumbent positions for 3 hours postprandially. Avoidance of tight, waist-
constricting clothing.
• Straining to defecate affects the contents of the stomach by creating additional pressure;
prevention and management of constipation are important.
Peptic Ulcer Disease (PUD)
Normal gastric and duodenal mucosa is protected from the digestive actions of acid and pepsin
by the secretion of mucus, the production of bicarbonate, the removal of excess acid by normal
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Internal Medicine (Nutrition_3) Dr Ammar Waham Ashor
blood flow, and the rapid renewal and repair of epithelial cell injury. Peptic ulcer refers to an
ulcer that occurs as a result of the breakdown of these normal defence and repair mechanisms.
Typically, more than one of the mechanisms must be malfunctioning for symptomatic peptic
ulcers to develop. Peptic ulcers typically show evidence of chronic inflammation and repair
processes surrounding the lesion. The primary causes of peptic ulcers are H. pylori infection,
gastritis, use of aspirin, other NSAIDs and corticosteroids, and severe illness.
MNT of Peptic Ulcer Disease (PUD)
• In persons with atrophic gastritis, vitamin B12 status should be evaluated because of lack of
intrinsic factor and gastric acid results in malabsorption of this vitamin.
• Low acid states may influence absorption of iron, calcium, and other nutrients because
gastric acid enhances bioavailability.
• In the case of iron deficiency anaemia, other causes may be the presence of H. pylori and
gastritis. Eradication of H. pylori has resulted in improved absorption of iron and increased
ferritin levels.
• Dietary recommendations are formed from individual tolerance and should be considered
supplemental to pharmacologic therapy.
• No conclusive evidence supports use of a traditional “bland” diet to decrease gastric acid
secretion or increase the time it takes to heal ulcers.
• General nutritional therapeutic recommendations include the following:
▪ Emphasize a balanced, nutritious diet.
▪ Limit the following foods and seasonings, and encourage avoidance of lifestyle habits
known to increase acid secretion, inhibit healing, or both:
• Caffeine (including coffee, tea, or decaffeinated coffee)
• Black pepper
• Chocolate
• Foods that are irritating or not well tolerated
• Alcohol
• Eating less than 2 hours before bedtime.
Celiac Disease and Gluten Sensitivity
Celiac disease is a chronic autoimmune disorder in which the mucosa of the small intestine,
especially the duodenum and proximal jejunum, is damaged by dietary gluten. The gliadin
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Internal Medicine (Nutrition_3) Dr Ammar Waham Ashor
fraction in wheat, secalin in rye, and hordein in barley are the specific prolamins (storage
proteins), collectively known as gluten, that trigger the toxic reaction in genetically predisposed
individuals.
Although the classic symptoms are diarrhoea, abdominal distention, fat malabsorption, and
weight loss, many patients do not present with GI symptoms or are asymptomatic. Others may
experience anaemia, osteoporosis, infertility, or even lymphoma if their disease is untreated.
MNT of Celiac Disease
• In general, patients should be assessed for nutrient deficiencies. In all newly diagnosed
patients, the clinician should consider checking levels of ferritin, red blood cell folate, and
25-OH vitamin D.
• If patients present with more severe symptoms, such as diarrhoea, weight loss,
malabsorption, or signs of nutrient deficiencies (e.g., night-blindness, neuropathy,
prolonged prothrombin time), other vitamins such as fat-soluble vitamins (A, E, K) and
minerals (zinc) should be checked.
• Once gluten is removed from the diet, symptoms gradually improve over the following
weeks and months. Intestinal mucosa subsequently returns to a near normal condition.
• Wheat and rye are the main sources of gluten-like proteins; it is also present in oats and
barley. Thus, these four grains have always been eliminated from the diet. However, a
growing body of evidence suggests that moderate amounts of oats may be safely used in
diets of most adults with Celiac disease. Corn and rice are usually the substitute grains used.
• The healing of the intestinal mucosa that occurs after initiation of a gluten-free diet
improves nutrient absorption, and many patients who eat well-balanced gluten-free diets
do not need nutritional supplementation.
• However, most specialty gluten-free products are not fortified with iron, folate, and other
B vitamins like other grain products, so the diet may not be as complete without at least
partial supplementation. Anaemia should be treated with iron, folate, or vitamin B12,
depending on the nature of the anaemia.
• Patients with malabsorption may benefit from a bone density scan to assess for osteopenia
or osteoporosis. Calcium and vitamin D supplementation are likely to be beneficial in these
patients.
• Electrolyte and fluid replacement is essential for those dehydrated from severe diarrhoea.
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Internal Medicine (Nutrition_3) Dr Ammar Waham Ashor
Irritable Bowel Syndrome
Irritable bowel syndrome (IBS) is a functional GI disorder involving disturbances between the
brain and the gut. Patients with IBS can be divided into subgroups with alternating bowel habits
(IBS-A), constipation-predominant IBS (IBSC), and diarrhoea-predominant IBS (IBS-D).
MNT of Irritable Bowel Syndrome
• Depending on the individual’s symptoms and food diary, lactose, gluten, or sugars may be
eliminated from the diet.
• The low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and
polyols) diet is now accepted as a strategy.
• The low-FODMAP diet limits high sugar intake, which increases osmolarity.
• Foods containing fructose (apples, pears, watermelon, figs, honey, fruit juice concentrate);
lactose (milk, ice cream, soft cheeses); polyols (sorbitol and mannitol) would be restricted.
• For patients with constipation-predominant IBS, a high-fiber diet (20 to 30g/day) may ease
symptoms.
Inflammatory Bowel Disease
Inflammatory bowel disease (IBD) refers to two chronic inflammatory conditions of the
intestines—ulcerative colitis (UC) and Crohn’s disease (regional enteritis). UC is an
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